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Akyol O, Yang CY, Woodside DG, Chiang HH, Chen CH, Gotto AM. Comparative Analysis of Atherogenic Lipoproteins L5 and Lp(a) in Atherosclerotic Cardiovascular Disease. Curr Atheroscler Rep 2024; 26:317-329. [PMID: 38753254 PMCID: PMC11192678 DOI: 10.1007/s11883-024-01209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE OF REVIEW Low-density lipoprotein (LDL) poses a risk for atherosclerotic cardiovascular disease (ASCVD). As LDL comprises various subtypes differing in charge, density, and size, understanding their specific impact on ASCVD is crucial. Two highly atherogenic LDL subtypes-electronegative LDL (L5) and Lp(a)-induce vascular cell apoptosis and atherosclerotic changes independent of plasma cholesterol levels, and their mechanisms warrant further investigation. Here, we have compared the roles of L5 and Lp(a) in the development of ASCVD. RECENT FINDINGS Lp(a) tends to accumulate in artery walls, promoting plaque formation and potentially triggering atherosclerosis progression through prothrombotic or antifibrinolytic effects. High Lp(a) levels correlate with calcific aortic stenosis and atherothrombosis risk. L5 can induce endothelial cell apoptosis and increase vascular permeability, inflammation, and atherogenesis, playing a key role in initiating atherosclerosis. Elevated L5 levels in certain high-risk populations may serve as a distinctive predictor of ASCVD. L5 and Lp(a) are both atherogenic lipoproteins contributing to ASCVD through distinct mechanisms. Lp(a) has garnered attention, but equal consideration should be given to L5.
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Affiliation(s)
- Omer Akyol
- Molecular Cardiology Research Laboratories, Vascular and Medicinal Research, The Texas Heart Institute, Houston, Texas, 77030, USA
| | - Chao-Yuh Yang
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, 77030, USA
| | - Darren G Woodside
- Molecular Cardiology Research Laboratories, The Texas Heart Institute, Houston, TX, 77030, USA
| | - Huan-Hsing Chiang
- Molecular Cardiology Research Laboratories, Vascular and Medicinal Research, The Texas Heart Institute, Houston, Texas, 77030, USA
| | - Chu-Huang Chen
- Molecular Cardiology Research Laboratories, Vascular and Medicinal Research, The Texas Heart Institute, Houston, Texas, 77030, USA.
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2
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Hedegaard BS, Nordestgaard BG, Kanstrup HL, Thomsen KK, Bech J, Bang LE, Henriksen FL, Andersen LJ, Gohr T, Larsen LH, Soja AMB, Elpert FP, Jakobsen TJ, Sjøl A, Joensen AM, Klausen IC, Schmidt EB, Bork CS. High Lipoprotein(a) May Explain One-Quarter of Clinical Familial Hypercholesterolemia Diagnoses in Danish Lipid Clinics. J Clin Endocrinol Metab 2024; 109:659-667. [PMID: 37862146 DOI: 10.1210/clinem/dgad625] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 10/22/2023]
Abstract
CONTEXT Cholesterol carried in lipoprotein(a) adds to measured low-density lipoprotein cholesterol (LDL-C) and may therefore drive some diagnoses of clinical familial hypercholesterolemia (FH). OBJECTIVE We investigated plasma lipoprotein(a) in individuals referred to Danish lipid clinics and evaluated the effect of plasma lipoprotein(a) on a diagnosis of FH. METHODS Individuals referred to 15 Danish lipid clinics who were suspected of having FH according to nationwide referral criteria were recruited between September 1, 2020 and November 30, 2021. All individuals were classified according to the Dutch Lipid Clinical Network criteria for FH before and after LDL-C was adjusted for 30% cholesterol content in lipoprotein(a). We calculated the fraction of individuals fulfilling a clinical diagnosis of FH partly due to elevated lipoprotein(a). RESULTS We included a total of 1166 individuals for analysis, of whom 206 fulfilled a clinical diagnosis of FH. Median lipoprotein(a) was 15 mg/dL (29 nmol/L) in those referred and 28% had lipoprotein(a) greater than or equal to 50 mg/dL (105 nmol/L), while 2% had levels greater than or equal to 180 mg/dL (389 nmol/L). We found that in 27% (55/206) of those fulfilling a clinical diagnosis of FH, this was partly due to high lipoprotein(a). CONCLUSION Elevated lipoprotein(a) was common in individuals referred to Danish lipid clinics and in one-quarter of individuals who fulfilled a clinical diagnosis of FH, this was partly due to elevated lipoprotein(a). These findings support the notion that the LPA gene should be considered an important causative gene in patients with clinical FH and further support the importance of measuring lipoprotein(a) when diagnosing FH as well as for stratification of cardiovascular risk.
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Affiliation(s)
- Berit Storgaard Hedegaard
- The Danish FH Study Group, Denmark
- Department of Cardiology, Regional Hospital Central Jutland, Viborg DK-8800, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg DK-9000, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital, Herlev-Gentofte DK-2730, Copenhagen, Denmark
| | - Børge Grønne Nordestgaard
- The Danish FH Study Group, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital, Herlev-Gentofte DK-2730, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen N DK-2200, Denmark
- The Copenhagen General Population Study, Copenhagen University Hospital, Herlev-Gentofte DK-2730, Copenhagen, Denmark
| | - Helle Lynge Kanstrup
- The Danish FH Study Group, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus DK-8200, Denmark
| | - Kristian Korsgaard Thomsen
- The Danish FH Study Group, Denmark
- Department of Cardiology, Hospital South West Jutland, University Hospital of Southern Denmark, Esbjerg DK-6700, Denmark
| | - Jan Bech
- The Danish FH Study Group, Denmark
| | - Lia Evi Bang
- The Danish FH Study Group, Denmark
- The Heart Center, Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen Ø DK-2100, Denmark
| | - Finn Lund Henriksen
- The Danish FH Study Group, Denmark
- Department of Cardiology, Odense University Hospital, Odense DK-5000, Denmark
| | - Lars Juel Andersen
- The Danish FH Study Group, Denmark
- Department of Cardiology, Zealand University Hospital, Roskilde DK-4000, Denmark
| | - Thomas Gohr
- The Danish FH Study Group, Denmark
- Department of Cardiology, Lillebælt Hospital, Kolding DK-6000, Denmark
| | - Linnea Hornbech Larsen
- The Danish FH Study Group, Denmark
- Department of Cardiology, Copenhagen University Hospital, Herlev-Gentofte, Hellerup DK-2900, Denmark
| | - Anne Merete Boas Soja
- The Danish FH Study Group, Denmark
- Department of Internal Medicine, Section of Cardiology, Holbæk Hospital, Holbæk DK-4300, Denmark
| | - Frank-Peter Elpert
- The Danish FH Study Group, Denmark
- Department of Cardiology, Hospital of Southern Jutland, Aabenraa DK-6200, Denmark
| | - Tomas Joen Jakobsen
- The Danish FH Study Group, Denmark
- Department of Cardiology, North Zealand Hospital, Frederikssund DK-3600, Denmark
| | - Anette Sjøl
- The Danish FH Study Group, Denmark
- Department of Cardiology, Amager-Hvidovre Hospital, Hvidovre DK-2650, Denmark
| | - Albert Marni Joensen
- The Danish FH Study Group, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg DK-9000, Denmark
- Department of Cardiology, North Denmark Regional Hospital, Hjørring DK-9800, Denmark
| | - Ib Christian Klausen
- The Danish FH Study Group, Denmark
- Department of Cardiology, Regional Hospital Central Jutland, Viborg DK-8800, Denmark
| | - Erik Berg Schmidt
- The Danish FH Study Group, Denmark
- Department of Cardiology, Regional Hospital Central Jutland, Viborg DK-8800, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg DK-9000, Denmark
| | - Christian Sørensen Bork
- The Danish FH Study Group, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg DK-9000, Denmark
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3
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Watts GF, Gidding SS, Hegele RA, Raal FJ, Sturm AC, Jones LK, Sarkies MN, Al-Rasadi K, Blom DJ, Daccord M, de Ferranti SD, Folco E, Libby P, Mata P, Nawawi HM, Ramaswami U, Ray KK, Stefanutti C, Yamashita S, Pang J, Thompson GR, Santos RD. International Atherosclerosis Society guidance for implementing best practice in the care of familial hypercholesterolaemia. Nat Rev Cardiol 2023; 20:845-869. [PMID: 37322181 DOI: 10.1038/s41569-023-00892-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 06/17/2023]
Abstract
This contemporary, international, evidence-informed guidance aims to achieve the greatest good for the greatest number of people with familial hypercholesterolaemia (FH) across different countries. FH, a family of monogenic defects in the hepatic LDL clearance pathway, is a preventable cause of premature coronary artery disease and death. Worldwide, 35 million people have FH, but most remain undiagnosed or undertreated. Current FH care is guided by a useful and diverse group of evidence-based guidelines, with some primarily directed at cholesterol management and some that are country-specific. However, none of these guidelines provides a comprehensive overview of FH care that includes both the lifelong components of clinical practice and strategies for implementation. Therefore, a group of international experts systematically developed this guidance to compile clinical strategies from existing evidence-based guidelines for the detection (screening, diagnosis, genetic testing and counselling) and management (risk stratification, treatment of adults or children with heterozygous or homozygous FH, therapy during pregnancy and use of apheresis) of patients with FH, update evidence-informed clinical recommendations, and develop and integrate consensus-based implementation strategies at the patient, provider and health-care system levels, with the aim of maximizing the potential benefit for at-risk patients and their families worldwide.
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Affiliation(s)
- Gerald F Watts
- School of Medicine, University of Western Australia, Perth, WA, Australia.
- Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia.
| | | | - Robert A Hegele
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine, Western University, London, ON, Canada
| | - Frederick J Raal
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy C Sturm
- Department of Genomic Health, Geisinger, Danville, PA, USA
- 23andMe, Sunnyvale, CA, USA
| | - Laney K Jones
- Department of Genomic Health, Geisinger, Danville, PA, USA
| | - Mitchell N Sarkies
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Khalid Al-Rasadi
- Medical Research Centre, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Dirk J Blom
- Division of Lipidology and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pedro Mata
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
| | - Hapizah M Nawawi
- Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM) and Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
- Specialist Lipid and Coronary Risk Prevention Clinics, Hospital Al-Sultan Abdullah (HASA) and Clinical Training Centre, Puncak Alam and Sungai Buloh Campuses, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Uma Ramaswami
- Royal Free London NHS Foundation Trust, University College London, London, UK
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, UK
| | - Claudia Stefanutti
- Department of Molecular Medicine, Extracorporeal Therapeutic Techniques Unit, Lipid Clinic and Atherosclerosis Prevention Centre, Regional Centre for Rare Diseases, Immunohematology and Transfusion Medicine, Umberto I Hospital, 'Sapienza' University of Rome, Rome, Italy
| | - Shizuya Yamashita
- Department of Cardiology, Rinku General Medical Center, Osaka, Japan
| | - Jing Pang
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | | | - Raul D Santos
- Lipid Clinic, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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4
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Borg SÁ, Joensen AM, Nielsen MRS, Olsen ÁW, Lolas IBY, Okkels H, Lundbye-Christensen S, Schmidt EB, Bork CS. Possible explanations for the common clinical familial hypercholesterolemia phenotypes in the Faroe Islands. J Clin Lipidol 2023; 17:633-642. [PMID: 37482509 DOI: 10.1016/j.jacl.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The prevalence of clinical familial hypercholesterolemia (FH) is very high in the Faroe Islands, but the possible causes are unknown. OBJECTIVES We aimed to describe potential genetic causes of FH in the Faroe Islands and to investigate whether levels of lipoprotein(a) and measures of dietary habits were associated with clinical FH in the Faroe Islands. METHODS In this case-control study, we identified potential clinical FH cases aged 18-75 years registered within a nationwide clinical laboratory database in the Faroe Islands and invited them for diagnostic evaluation according to clinical FH scoring systems. Controls were identified in the background population. Lipoprotein(a) was measured in plasma, while the fatty acid composition was determined in adipose tissue. The habitual diet of the participants was assessed using a food frequency questionnaire. Genetic testing for FH and polygenic variants was performed in a selection of clinical FH cases. RESULTS A total of 121 clinical FH cases and 123 age- and sex-matched controls were recruited. We found a very low frequency of monogenic FH (2.5%), but a high level of polygenic FH (63%) in those genetically tested (67%). High levels of plasma lipoprotein(a) were associated with high odds of clinical FH. Clinical FH cases had a lower intake of saturated fatty acids (SFAs) measured by a high fat-score and a lower content of SFAs in adipose tissue compared with controls. CONCLUSION The high prevalence of FH in the Faroe Islands may be due to polygenic causes of hypercholesterolemia and to a lesser extent other genetic factors and elevated plasma lipoprotein(a) levels.
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Affiliation(s)
- Sanna Á Borg
- Department of Medicine, National Hospital of the Faroe Islands, Tórshavn, Faroe Islands.
| | | | | | - Ása Wraae Olsen
- Department of Medicine, National Hospital of the Faroe Islands, Tórshavn, Faroe Islands
| | | | - Henrik Okkels
- Department of Molecular Diagnostics, Aalborg University Hospital, Aalborg, Denmark
| | | | - Erik Berg Schmidt
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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5
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Kronenberg F, Mora S, Stroes ESG, Ference BA, Arsenault BJ, Berglund L, Dweck MR, Koschinsky ML, Lambert G, Mach F, McNeal CJ, Moriarty PM, Natarajan P, Nordestgaard BG, Parhofer KG, Virani SS, von Eckardstein A, Watts GF, Stock JK, Ray KK, Tokgözoğlu LS, Catapano AL. Frequent questions and responses on the 2022 lipoprotein(a) consensus statement of the European Atherosclerosis Society. Atherosclerosis 2023; 374:107-120. [PMID: 37188555 DOI: 10.1016/j.atherosclerosis.2023.04.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/17/2023]
Abstract
In 2022, the European Atherosclerosis Society (EAS) published a new consensus statement on lipoprotein(a) [Lp(a)], summarizing current knowledge about its causal association with atherosclerotic cardiovascular disease (ASCVD) and aortic stenosis. One of the novelties of this statement is a new risk calculator showing how Lp(a) influences lifetime risk for ASCVD and that global risk may be underestimated substantially in individuals with high or very high Lp(a) concentration. The statement also provides practical advice on how knowledge about Lp(a) concentration can be used to modulate risk factor management, given that specific and highly effective mRNA-targeted Lp(a)-lowering therapies are still in clinical development. This advice counters the attitude: "Why should I measure Lp(a) if I can't lower it?". Subsequent to publication, questions have arisen relating to how the recommendations of this statement impact everyday clinical practice and ASCVD management. This review addresses 30 of the most frequently asked questions about Lp(a) epidemiology, its contribution to cardiovascular risk, Lp(a) measurement, risk factor management and existing therapeutic options.
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Affiliation(s)
- Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Samia Mora
- Center for Lipid Metabolomics, Division of Preventive Medicine, and Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Brian A Ference
- Centre for Naturally Randomized Trials, University of Cambridge, Cambridge, UK
| | - Benoit J Arsenault
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, and Department of Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Lars Berglund
- Department of Internal Medicine, School of Medicine, University of California-Davis, Davis, CA, USA
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, Edinburgh Heart Centre, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Gilles Lambert
- Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), Université de La Réunion, 97400, Saint-Pierre, La Réunion, France
| | - François Mach
- Department of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Catherine J McNeal
- Division of Cardiology, Department of Internal Medicine Baylor Scott & White Health, 2301 S. 31st St., Temple, TX, 76508, USA
| | - Patrick M Moriarty
- Atherosclerosis and Lipoprotein-apheresis Clinic, University of Kansas Medical Center, Kansas City, KS, USA
| | - Pradeep Natarajan
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; and Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus G Parhofer
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians University Klinikum, Munich, Germany
| | - Salim S Virani
- The Aga Khan University, Karachi, Pakistan; Texas Heart Institute, Baylor College of Medicine, Houston, TX, USA
| | - Arnold von Eckardstein
- Institute of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gerald F Watts
- Medical School, University of Western Australia, and Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
| | - Jane K Stock
- European Atherosclerosis Society, Mässans Gata 10, SE-412 51, Gothenburg, Sweden
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Lale S Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, and IRCCS MultiMedica, Milan, Italy
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Thayabaran D, Tsui APT, Ebmeier S, Cegla J, David A, Jones B. The effect of adjusting LDL-cholesterol for Lp(a)-cholesterol on the diagnosis of familial hypercholesterolaemia. J Clin Lipidol 2023; 17:244-254. [PMID: 36870882 DOI: 10.1016/j.jacl.2023.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Familial hypercholesterolaemia (FH) diagnostic tools help prioritise patients for genetic testing and include LDL-C estimates commonly calculated using the Friedewald equation. However, cholesterol contributions from lipoprotein(a) (Lp(a)) can overestimate 'true' LDL-C, leading to potentially inappropriate clinical FH diagnosis. OBJECTIVE To assess how adjusting LDL-C for Lp(a)-cholesterol affects FH diagnoses using Simon Broome (SB) and Dutch Lipid Clinic Network (DLCN) criteria. METHODS Adults referred to a tertiary lipid clinic in London, UK were included if they had undergone FH genetic testing based on SB or DLCN criteria. LDL-C was adjusted for Lp(a)-cholesterol using estimated cholesterol contents of 17.3%, 30% and 45%, and the effects of these adjustments on reclassification to 'unlikely' FH and diagnostic accuracy were determined. RESULTS Depending on the estimated cholesterol content applied, LDL-C adjustment reclassified 8-23% and 6-17% of patients to 'unlikely' FH using SB and DLCN criteria, respectively. The highest reclassification rates were observed following 45% adjustment in mutation-negative patients with higher Lp(a) levels. This led to an improvement in diagnostic accuracy (46% to 57% with SB, and 32% to 44% with DLCN following 45% adjustment) through increased specificity. However all adjustment factors led to erroneous reclassification of mutation-positive patients to 'unlikely' FH. CONCLUSION LDL-C adjustment for Lp(a)-cholesterol improves the accuracy of clinical FH diagnostic tools. Adopting this approach would reduce unnecessary genetic testing but also incorrectly reclassify mutation-positive patients. Health economic analysis is needed to balance the risks of over- and under-diagnosis before LDL-C adjustments for Lp(a) can be recommended.
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Affiliation(s)
- Darmiga Thayabaran
- Imperial College Healthcare NHS Trust, London, UK (Drs Thayabaran, Cegla, David and Jones)
| | | | - Stefan Ebmeier
- Department of Infectious Diseases, Imperial College London, London, UK (Dr Ebmeier)
| | - Jaimini Cegla
- Imperial College Healthcare NHS Trust, London, UK (Drs Thayabaran, Cegla, David and Jones); Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK (Drs Cegla and Jones)
| | - Alessia David
- Imperial College Healthcare NHS Trust, London, UK (Drs Thayabaran, Cegla, David and Jones); Department of Life Sciences, Imperial College London, London, UK (Dr David)
| | - Ben Jones
- Imperial College Healthcare NHS Trust, London, UK (Drs Thayabaran, Cegla, David and Jones); Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK (Drs Cegla and Jones).
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7
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Tromp TR, Ibrahim S, Nurmohamed NS, Peter J, Zuurbier L, Defesche JC, Reeskamp LF, Hovingh GK, Stroes ESG. Use of Lipoprotein(a) to improve diagnosis and management in clinical familial hypercholesterolemia. Atherosclerosis 2023; 365:27-33. [PMID: 36473758 DOI: 10.1016/j.atherosclerosis.2022.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/08/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Lipoprotein(a) (Lp(a)) is an LDL-like particle whose plasma levels are largely genetically determined. The impact of measuring Lp(a) in patients with clinical familial hypercholesterolemia (FH) referred for genetic testing is largely unknown. We set out to evaluate the contribution of (genetically estimated) Lp(a) in a large nation-wide referral population of clinical FH. METHODS In 1504 patients referred for FH genotyping, we used an LPA genetic instrument (rs10455872 and rs3798220) as a proxy for plasma Lp(a) levels. The genetic Lp(a) proxy was used to correct LDL-cholesterol and reclassify patients with clinical FH based on Dutch Lipid Criteria Network (DLCN) scoring. Finally, we used estimated Lp(a) levels to reclassify ASCVD risk using the SCORE and SMART risk scores. RESULTS LPA SNPs were more prevalent among mutation-negative compared with mutation-positive patients (296/1280 (23.1%) vs 35/224 (15.6%), p = 0.016). Among patients with genetically defined high Lp(a) levels, 9% were reclassified to the DLCN category 'unlikely FH' using Lp(a)-corrected LDL-cholesterol (LDL-Ccor) and all but one of these patients indeed carried no FH variant. Furthermore, elevated Lp(a) reclassified predicted ASCVD risk into a higher category in up to 18% of patients. CONCLUSIONS In patients referred for FH molecular testing, we show that taking into account (genetically estimated) Lp(a) levels not only results in reclassification of probability of genetic FH, but also has an impact on individual cardiovascular risk evaluation. However, to avoid missing the diagnosis of an FH variant, clear thresholds for the use of Lp(a)-cholesterol adjusted LDL-cholesterol levels in patients referred for genetic testing of FH must be established.
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Affiliation(s)
- Tycho R Tromp
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Shirin Ibrahim
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Nick S Nurmohamed
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - Jorge Peter
- Department of Experimental Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Linda Zuurbier
- Department of Human Genetics, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Joep C Defesche
- Department of Human Genetics, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Laurens F Reeskamp
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Internal Medicine, OLVG Oost, Amsterdam, the Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Novo Nordisk A/S, Copenhagen, Denmark
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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8
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Nestel P, Loh WJ, Ward NC, Watts GF. New Horizons: Revival of Lipoprotein (a) as a Risk Factor for Cardiovascular Disease. J Clin Endocrinol Metab 2022; 107:e4281-e4294. [PMID: 36108076 DOI: 10.1210/clinem/dgac541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Indexed: 02/13/2023]
Abstract
The status of lipoprotein (a) [Lp(a)] as a cardiovascular risk factor has been resurrected by advances in genetics. Mendelian randomization studies show a causal link of Lp(a) with coronary artery disease (CAD), peripheral artery disease (PAD), and calcific aortic valve stenosis (CAVS). The genetics of Lp(a) is complex and extends beyond the kringle-IV type 2, as it is also dependent on ancestry. The plasma concentration of Lp(a) is determined by the hepatic production of apolipoprotein(a) [apo(a)] component of Lp(a), supporting the use of nucleic acids that inhibit the messenger RNA (mRNA) gene transcript for apo(a). Analytical barriers to measurement of Lp(a) are being addressed using isoform independent assays and a traceable standard. The association of Lp(a) and atherosclerotic cardiovascular disease is higher for myocardial infarction than PAD and CAVS. Increased risk of type 2 diabetes mellitus associated with low Lp(a) levels is perplexing and requires further investigation. The greatest advancement in Lp(a)-lowering therapies is based on using RNA therapeutics that are now being investigated in clinical trials. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition lowers Lp(a) modestly, but whether cardiovascular benefit is independent of low-density lipoprotein lowering remains unclear. Opportunistic and selective testing for Lp(a) is supported by moderate evidence, with the case for universal screening premature. Modification of behavioral and clinical risk factors may be targeted to mitigate Lp(a)-mediated risk of cardiovascular disease. Clinical practice guidelines have been developed to address gaps in care of high Lp(a), but full implementation awaits the findings of clinical outcome trials using RNA-directed therapies currently underway.
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Affiliation(s)
- Paul Nestel
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Wann Jia Loh
- School of Medicine, University of Western Australia, Perth, Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
- Department of Endocrinology, Changi General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Natalie C Ward
- School of Medicine, University of Western Australia, Perth, Australia
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
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9
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de Boer LM, Hutten BA, Zwinderman AH, Wiegman A. Lipoprotein(a) levels in children with suspected familial hypercholesterolaemia: a cross-sectional study. Eur Heart J 2022; 44:1421-1428. [PMID: 36382390 PMCID: PMC10119030 DOI: 10.1093/eurheartj/ehac660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 09/14/2022] [Accepted: 11/01/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS Familial hypercholesterolaemia (FH) predisposes children to the early initiation of atherosclerosis and is preferably diagnosed by DNA analysis. Yet, in many children with a clinical presentation of FH, no mutation is found. Adult data show that high levels of lipoprotein(a) [Lp(a)] may underlie a clinical presentation of FH, as the cholesterol content of Lp(a) is included in conventional LDL cholesterol measurements. As this is limited to adult data, Lp(a) levels in children with and without (clinical) FH were evaluated. METHODS AND RESULTS Children were eligible if they visited the paediatric lipid clinic (1989-2020) and if Lp(a) measurement and DNA analysis were performed. In total, 2721 children (mean age: 10.3 years) were included and divided into four groups: 1931 children with definite FH (mutation detected), 290 unaffected siblings/normolipidaemic controls (mutation excluded), 108 children with probable FH (clinical presentation, mutation not detected), and 392 children with probable non-FH (no clinical presentation, mutation not excluded). In children with probable FH, 32% were found to have high Lp(a) [geometric mean (95% confidence interval) of 15.9 (12.3-20.6) mg/dL] compared with 10 and 10% [geometric means (95% confidence interval) of 11.5 (10.9-12.1) mg/dL and 9.8 (8.4-11.3) mg/dL] in children with definite FH (P = 0.017) and unaffected siblings (P = 0.002), respectively. CONCLUSION Lp(a) was significantly higher and more frequently elevated in children with probable FH compared with children with definite FH and unaffected siblings, suggesting that high Lp(a) may underlie the clinical presentation of FH when no FH-causing mutation is found. Performing both DNA analysis and measuring Lp(a) in all children suspected of FH is recommended to assess possible LDL cholesterol overestimation related to increased Lp(a).
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Affiliation(s)
- Lotte M de Boer
- Epidemiology and Data Science, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, TheNetherlands.,Pediatrics, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, TheNetherlands
| | - Barbara A Hutten
- Epidemiology and Data Science, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, TheNetherlands.,Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Epidemiology and Data Science, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, TheNetherlands.,Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Albert Wiegman
- Pediatrics, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, TheNetherlands.,Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
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10
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Familial Hypercholesterolemia and Lipoprotein(a): A Gordian Knot in Cardiovascular Prevention. Metabolites 2022; 12:metabo12111065. [PMID: 36355148 PMCID: PMC9693181 DOI: 10.3390/metabo12111065] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022] Open
Abstract
Familial hypercholesterolemia (FH) is the most frequent genetic disorder resulting in increased low-density lipoprotein cholesterol (LDL-C) levels from childhood, leading to premature atherosclerotic cardiovascular disease (ASCVD) if left untreated. FH diagnosis is based on clinical criteria and/or genetic testing and its prevalence is estimated as being up to 1:300,000−400,000 for the homozygous and ~1:200−300 for the heterozygous form. Apart from its late diagnosis, FH is also undertreated, despite the available lipid-lowering therapies. In addition, elevated lipoprotein(a) (Lp(a)) (>50 mg/dL; 120 nmol/L), mostly genetically determined, has been identified as an important cardiovascular risk factor with prevalence rate of ~20% in the general population. Novel Lp(a)-lowering therapies have been recently developed and their cardiovascular efficacy is currently investigated. Although a considerable proportion of FH patients is also diagnosed with high Lp(a) levels, there is a debate whether these two entities are associated. Nevertheless, Lp(a), particularly among patients with FH, has been established as a significant cardiovascular risk factor. In this narrative review, we present up-to-date evidence on the pathophysiology, diagnosis, and treatment of both FH and elevated Lp(a) with a special focus on their association and joint effect on ASCVD risk.
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11
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Abstract
Purpose of Review Over the past decades, genetic and observational evidence has positioned lipoprotein(a) as novel important and independent risk factor for cardiovascular disease (ASCVD) and aortic valve stenosis. Recent Findings As Lp(a) levels are determined genetically, lifestyle interventions have no effect on Lp(a)-mediated ASCVD risk. While traditional low-density lipoprotein cholesterol (LDL-C) can now be effectively lowered in the vast majority of patients, current lipid lowering therapies have no clinically relevant Lp(a) lowering effect. Summary There are multiple Lp(a)-directed therapies in clinical development targeting LPA mRNA that have shown to lower Lp(a) plasma levels for up to 90%: pelacarsen, olpasiran, and SLN360. Pelacarsen is currently investigated in a phase 3 cardiovascular outcome trial expected to finish in 2024, while olpasiran is about to proceed to phase 3 and SLN360’s phase 1 outcomes were recently published. If proven efficacious, Lp(a) will soon become the next pathway to target in ASCVD risk management.
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12
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Kronenberg F, Mora S, Stroes ESG, Ference BA, Arsenault BJ, Berglund L, Dweck MR, Koschinsky M, Lambert G, Mach F, McNeal CJ, Moriarty PM, Natarajan P, Nordestgaard BG, Parhofer KG, Virani SS, von Eckardstein A, Watts GF, Stock JK, Ray KK, Tokgözoğlu LS, Catapano AL. Lipoprotein(a) in atherosclerotic cardiovascular disease and aortic stenosis: a European Atherosclerosis Society consensus statement. Eur Heart J 2022; 43:3925-3946. [PMID: 36036785 PMCID: PMC9639807 DOI: 10.1093/eurheartj/ehac361] [Citation(s) in RCA: 317] [Impact Index Per Article: 158.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/10/2022] [Accepted: 06/21/2022] [Indexed: 12/20/2022] Open
Abstract
This 2022 European Atherosclerosis Society lipoprotein(a) [Lp(a)] consensus statement updates evidence for the role of Lp(a) in atherosclerotic cardiovascular disease (ASCVD) and aortic valve stenosis, provides clinical guidance for testing and treating elevated Lp(a) levels, and considers its inclusion in global risk estimation. Epidemiologic and genetic studies involving hundreds of thousands of individuals strongly support a causal and continuous association between Lp(a) concentration and cardiovascular outcomes in different ethnicities; elevated Lp(a) is a risk factor even at very low levels of low-density lipoprotein cholesterol. High Lp(a) is associated with both microcalcification and macrocalcification of the aortic valve. Current findings do not support Lp(a) as a risk factor for venous thrombotic events and impaired fibrinolysis. Very low Lp(a) levels may associate with increased risk of diabetes mellitus meriting further study. Lp(a) has pro-inflammatory and pro-atherosclerotic properties, which may partly relate to the oxidized phospholipids carried by Lp(a). This panel recommends testing Lp(a) concentration at least once in adults; cascade testing has potential value in familial hypercholesterolaemia, or with family or personal history of (very) high Lp(a) or premature ASCVD. Without specific Lp(a)-lowering therapies, early intensive risk factor management is recommended, targeted according to global cardiovascular risk and Lp(a) level. Lipoprotein apheresis is an option for very high Lp(a) with progressive cardiovascular disease despite optimal management of risk factors. In conclusion, this statement reinforces evidence for Lp(a) as a causal risk factor for cardiovascular outcomes. Trials of specific Lp(a)-lowering treatments are critical to confirm clinical benefit for cardiovascular disease and aortic valve stenosis.
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Affiliation(s)
- Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Samia Mora
- Center for Lipid Metabolomics, Division of Preventive Medicine, and Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Brian A Ference
- Centre for Naturally Randomized Trials, University of Cambridge, Cambridge, UK
| | - Benoit J Arsenault
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, and Department of Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Lars Berglund
- Department of Internal Medicine, School of Medicine, University of California-Davis, Davis, Sacramento, CA, USA
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, Edinburgh Heart Centre, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Marlys Koschinsky
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Gilles Lambert
- Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), Université de La Réunion, 97400 Saint-Denis de La Reunion, France
| | - François Mach
- Department of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Catherine J McNeal
- Division of Cardiology, Department of Internal Medicine, Baylor Scott & White Health, 2301 S. 31st St., USA
| | | | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, and Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus G Parhofer
- Medizinische Klinik und Poliklinik IV, Ludwigs- Maximilians University Klinikum, Munich, Germany
| | - Salim S Virani
- Section of Cardiovascular Research, Baylor College of Medicine & Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Arnold von Eckardstein
- Institute of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gerald F Watts
- Medical School, University of Western Australia, and Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
| | - Jane K Stock
- European Atherosclerosis Society, Mässans Gata 10, SE-412 51 Gothenburg, Sweden
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Lale S Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milano, Milano, Italy.,IRCCS Multimedica, Milano, Italy
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13
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Šuran D, Blažun Vošner H, Završnik J, Kokol P, Sinkovič A, Kanič V, Kokol M, Naji F, Završnik T. Lipoprotein(a) in Cardiovascular Diseases: Insight From a Bibliometric Study. Front Public Health 2022; 10:923797. [PMID: 35865239 PMCID: PMC9294325 DOI: 10.3389/fpubh.2022.923797] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Lipoprotein(a) [Lp(a)] is a complex polymorphic lipoprotein comprised of a low-density lipoprotein particle with one molecule of apolipoprotein B100 and an additional apolipoprotein(a) connected through a disulfide bond. The serum concentration is mostly genetically determined and only modestly influenced by diet and other lifestyle modifications. In recent years it has garnered increasing attention due to its causal role in pre-mature atherosclerotic cardiovascular disease and calcific aortic valve stenosis, while novel effective therapeutic options are emerging [apolipoprotein(a) antisense oligonucleotides and ribonucleic acid interference therapy]. Bibliometric descriptive analysis and mapping of the research literature were made using Scopus built-in services. We focused on the distribution of documents, literature production dynamics, most prolific source titles, institutions, and countries. Additionally, we identified historical and influential papers using Reference Publication Year Spectrography (RPYS) and the CRExplorer software. An analysis of author keywords showed that Lp(a) was most intensively studied regarding inflammation, atherosclerosis, cardiovascular risk assessment, treatment options, and hormonal changes in post-menopausal women. The results provide a comprehensive view of the current Lp(a)-related literature with a specific interest in its role in calcific aortic valve stenosis and potential emerging pharmacological interventions. It will help the reader understand broader aspects of Lp(a) research and its translation into clinical practice.
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Affiliation(s)
- David Šuran
- Department of Cardiology and Angiology, University Medical Centre Maribor, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- *Correspondence: David Šuran
| | - Helena Blažun Vošner
- Community Healthcare Centre Dr. Adolf Drolc Maribor, Maribor, Slovenia
- Faculty of Health and Social Sciences Slovenj Gradec, Slovenj Gradec, Slovenia
- Alma Mater Europaea, Maribor, Slovenia
| | - Jernej Završnik
- Community Healthcare Centre Dr. Adolf Drolc Maribor, Maribor, Slovenia
- Alma Mater Europaea, Maribor, Slovenia
| | - Peter Kokol
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Faculty of Electrical Engineering and Computer Science, University of Maribor, Maribor, Slovenia
| | - Andreja Sinkovič
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Department of Medical Intensive Care, University Medical Centre Maribor, Maribor, Slovenia
| | - Vojko Kanič
- Department of Cardiology and Angiology, University Medical Centre Maribor, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Marko Kokol
- Faculty of Electrical Engineering and Computer Science, University of Maribor, Maribor, Slovenia
- Semantika Research, Semantika d.o.o., Maribor, Slovenia
| | - Franjo Naji
- Department of Cardiology and Angiology, University Medical Centre Maribor, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Tadej Završnik
- Department of Cardiology and Angiology, University Medical Centre Maribor, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
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14
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Lipoprotein(a) measurement issues: Are we making a mountain out of a molehill? Atherosclerosis 2022; 349:123-135. [PMID: 35606072 DOI: 10.1016/j.atherosclerosis.2022.04.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/24/2022] [Accepted: 04/05/2022] [Indexed: 12/26/2022]
Abstract
Lipoprotein(a) [Lp(a)] became besides LDL cholesterol one of the most attractive targets for intervention in cardiovascular disease. Strong genetic evidence supports the causal association between high Lp(a) concentrations and cardiovascular outcomes. Since specific Lp(a)-lowering therapies are under clinical investigation, the interest in measuring Lp(a) has markedly increased. However, the special structure of the lead protein component of Lp(a), named apolipoprotein(a), creates difficulties for an accurate measurement of Lp(a). A highly homologous repetitive structure, called kringle IV repeat with up to more the 40 repeats, causes a highly polymorphic protein. Antibodies raised against apolipoprotein(a) are mostly directed against the repetitive structure of this protein, which complicates the measurement of Lp(a) in molar terms. Both measurements in mass (mg/dL) and molar terms (nmol/L) are described and a conversion from one into the another unit is only approximately possible. Working groups for standardization of Lp(a) measurements are going to prepare widely available and improved reference materials, which will be a major step for the measurement of Lp(a). This review discusses many aspects of the difficulties in measuring Lp(a). It tries to distinguish between academic and practical concerns and warns to make a mountain out of a molehill, which does no longer allow to see the patient behind that mountain by simply staring at the laboratory issues. On the other hand, the calibration of some assays raises major concerns, which are anything else but a molehill. This should be kept in mind and we should start measuring Lp(a) with the aim of a better risk stratification for the patient and to identify those patients who might be in urgent need for a specific Lp(a)-lowering therapy as soon as it becomes available.
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15
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Loh WJ, Chan DC, Mata P, Watts GF. Familial Hypercholesterolemia and Elevated Lipoprotein(a): Cascade Testing and Other Implications for Contextual Models of Care. Front Genet 2022; 13:905941. [PMID: 35571022 PMCID: PMC9091303 DOI: 10.3389/fgene.2022.905941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Elevated lipoprotein(a) [Lp(a)], a predominantly genetic disorder, is a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valvular disease, particularly in patients with familial hypercholesterolemia (FH), a Tier I genomic condition. The combination from birth of the cumulative exposure to elevated plasma concentrations of both Lp(a) and low-density lipoprotein is particularly detrimental and explains the enhanced morbidity and mortality risk observed in patients with both conditions. An excellent opportunity to identify at-risk patients with hyper-Lp(a) at increased risk of ASCVD is to test for hyper-Lp(a) during cascade testing for FH. With probands having FH and hyper-Lp(a), the yield of detection of hyper-Lp(a) is 1 individual for every 2.1-2.4 relatives tested, whereas the yield of detection of both conditions is 1 individual for every 3-3.4 relatives tested. In this article, we discuss the incorporation of assessment of Lp(a) in the cascade testing in FH as a feasible and crucial part of models of care for FH. We also propose a simple management tool to help physicians identify and manage elevated Lp(a) in FH, with implications for the care of Lp(a) beyond FH, noting that the clinical use of RNA therapeutics for specifically targeting the overproduction of Lp(a) in at risk patients is still under investigation.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Dick C Chan
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Pedro Mata
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
| | - Gerald F Watts
- Medical School, University of Western Australia, Perth, WA, Australia.,Lipid Disorders Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia
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16
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Anagnostis P, Rizos CV, Skoumas I, Rallidis L, Tziomalos K, Skalidis E, Kotsis V, Doumas M, Kolovou G, Sfikas G, Garoufi A, Lambadiari V, Dima I, Kiouri E, Agapakis D, Zacharis E, Antza C, Kolovou V, Koumaras C, Bantouvakis G, Liamis G, Liberopoulos EN. Association between lipoprotein(a) concentrations and atherosclerotic cardiovascular disease risk in patients with familial hypercholesterolemia: an analysis from the HELLAS-FH. Endocrine 2022; 76:324-330. [PMID: 35262845 DOI: 10.1007/s12020-022-03013-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 02/06/2022] [Indexed: 11/03/2022]
Abstract
AIMS Lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD) in the general population. However, such a role in patients with familial hypercholesterolemia (FH) is less documented. The purpose of this study was to evaluate the association between Lp(a) concentrations and ASCVD prevalence in adult patients with FH. METHODS This was a cross-sectional study from the Hellenic Familial Hypercholesterolemia Registry (HELLAS-FH). Patients were categorized into 3 tertiles according to Lp(a) levels. RESULTS A total of 541 adult patients (249 males) with possible/probable/definite FH heterozygous FH (HeFH) were included (mean age 48.5 ± 15.0 years at registration, 40.8 ± 15.9 years at diagnosis). Median (interquartile range) Lp(a) concentrations in the 1st, 2nd and 3rd Lp(a) tertile were 6.4 (3.0-9.7), 22.4 (16.0-29.1) and 77.0 (55.0-102.0) mg/dL, respectively. There was no difference in lipid profile across Lp(a) tertiles. The overall prevalence of ASCVD was 9.4% in the first, 16.1% in the second and 20.6% in the third tertile (p = 0.012 among tertiles). This was also the case for premature ASCVD, with prevalence rates of 8.5, 13.4 and 19.8%, respectively (p = 0.010 among tertiles). A trend for increasing prevalence of coronary artery disease (8.3, 12.2 and 16.1%, respectively; p = 0.076 among tertiles) was also observed. No difference in the prevalence of stroke and peripheral artery disease was found across tertiles. CONCLUSIONS Elevated Lp(a) concentrations are significantly associated with increased prevalence of ASCVD in patients with possible/probable/definite HeFH.
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Affiliation(s)
- Panagiotis Anagnostis
- Department of Endocrinology, Police Medical Centre of Thessaloniki, Thessaloniki, Greece
| | - Christos V Rizos
- Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Ioannis Skoumas
- Cardiology Clinic, Hippokration General Hospital, Athens, Greece
| | - Loukianos Rallidis
- Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Konstantinos Tziomalos
- 1st Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Emmanuel Skalidis
- Cardiology Clinic, University General Hospital of Heraklion, Heraklion, Greece
| | - Vasileios Kotsis
- Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Papageorgiou General Hospital Thessaloniki, Thessaloniki, Greece
| | - Michalis Doumas
- 2nd Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - Genovefa Kolovou
- Cardiometabolic Center, Lipid Clinic, LA apheresis Unit, Metropolitan Hospital, Athens, Greece
| | - George Sfikas
- Department of Internal Medicine, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Anastasia Garoufi
- Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, Β' Pediatrics Clinic, General Children's Hospital "Pan. & Aglaia Kyriakou", Athens, Greece
| | - Vaia Lambadiari
- 2nd Propedeutic Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Ioanna Dima
- Cardiology Clinic, Hippokration General Hospital, Athens, Greece
| | - Estela Kiouri
- Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Dimitrios Agapakis
- 1st Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
- Department of Internal Medicine, General Hospital of Goumenissa, Goumenissa, Greece
| | - Evangelos Zacharis
- Cardiology Clinic, University General Hospital of Heraklion, Heraklion, Greece
| | - Christina Antza
- Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Papageorgiou General Hospital Thessaloniki, Thessaloniki, Greece
| | - Vana Kolovou
- Cardiometabolic Center, Lipid Clinic, LA apheresis Unit, Metropolitan Hospital, Athens, Greece
| | - Charalambos Koumaras
- Department of Internal Medicine, 424 General Military Training Hospital, Thessaloniki, Greece
| | - George Bantouvakis
- Cardiology Clinic, University General Hospital of Heraklion, Heraklion, Greece
| | - George Liamis
- Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Evangelos N Liberopoulos
- Department of Endocrinology, Police Medical Centre of Thessaloniki, Thessaloniki, Greece.
- Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece.
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17
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Langsted A, Nordestgaard BG. Lipoprotein(a) as Part of the Diagnosis of Clinical Familial Hypercholesterolemia. Curr Atheroscler Rep 2022; 24:289-296. [PMID: 35107760 DOI: 10.1007/s11883-022-01002-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Individuals with familial hypercholesterolemia have very high risk of cardiovascular disease due to lifelong elevations in LDL cholesterol. Elevated lipoprotein(a) is a risk factor for cardiovascular diseases such as myocardial infarction and aortic valve stenosis. It has been proposed to include elevated lipoprotein(a) in the diagnosis of clinical familial hypercholesterolemia. RECENT FINDINGS Lipoprotein(a) is co-measured in LDL cholesterol, and up to one-quarter of all diagnoses of clinical familial hypercholesterolemia are due to high levels of lipoprotein(a). Further, individuals with both familial hypercholesterolemia and elevated lipoprotein(a) have an extremely high risk of myocardial infarction. We discuss the background for familial hypercholesterolemia and elevated lipoprotein(a) as risk factors for cardiovascular disease and the consequences of the fact that LDL cholesterol measurements/calculations include the cholesterol present in lipoprotein(a). Finally, we discuss the potential of including lipoprotein(a) as part of the diagnosis of familial hypercholesterolemia and in consequence possible treatments.
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Affiliation(s)
- Anne Langsted
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls vej 1, 2730, Herlev, Denmark.
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls vej 1, 2730, Herlev, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls vej 1, 2730, Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Borgmester Ib Juuls vej 1, 2730, Herlev, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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18
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Chubykina UV, Ezhov MV, Afanasieva OI, Klesareva EA, Pokrovsky SN. Elevated Lipoprotein(a) Level Influences Familial Hypercholesterolemia Diagnosis. Diseases 2022; 10:diseases10010006. [PMID: 35225859 PMCID: PMC8884002 DOI: 10.3390/diseases10010006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 02/03/2023] Open
Abstract
Familial hypercholesterolemia (FH) and elevated lipoprotein(a) [Lp(a)] level are the most common inherited disorders of lipid metabolism. This study evaluated the impact of high Lp(a) level on accuracy Dutch Lipid Clinic Network (DLCN) criteria of heterozygous FH diagnosis. A group of 206 individuals not receiving lipid-lowering medication with low-density lipoprotein cholesterol (LDL-C) >4.9 mmol/L was chosen from the Russian FH Registry. LDL-C corrected for Lp(a)-cholesterol was calculated as LDL-C − 0.3 × Lp(a). DLCN criteria were applied before and after adjusting LDL-C concentration. Of the 206 patients with potential FH, a total of 34 subjects (17%) were reclassified to less severe FH diagnosis, 13 subjects of them (6%) were reclassified to “unlike” FH. In accordance with Receiver Operating Characteristic curve, Lp(a) level ≥40 mg/dL was associated with FH re-diagnosing with sensitivity of 63% and specificity of 78% (area under curve = 0.7, 95% CI 0.7−0.8, p < 0.001). The reclassification was mainly observed in FH patients with Lp(a) level above 40 mg/dL, i.e., 33 (51%) with reclassified DLCN criteria points and 22 (34%) with reclassified diagnosis, compared with 21 (15%) and 15 (11%), respectively, in patients with Lp(a) level less than 40 mg/dL. Thus, LDL-C corrected for Lp(a)-cholesterol should be considered in all FH patients with Lp(a) level above 40 mg/dL for recalculating points in accordance with DLCN criteria.
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Affiliation(s)
- Uliana V. Chubykina
- A.L. Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia;
| | - Marat V. Ezhov
- A.L. Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia;
- Correspondence:
| | - Olga I. Afanasieva
- Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia; (O.I.A.); (E.A.K.); (S.N.P.)
| | - Elena A. Klesareva
- Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia; (O.I.A.); (E.A.K.); (S.N.P.)
| | - Sergei N. Pokrovsky
- Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia; (O.I.A.); (E.A.K.); (S.N.P.)
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19
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Tromp TR, Hovingh GK, Reeskamp LF. Letter by Tromp et al Regarding Article, "Large-Scale Screening for Monogenic and Clinically Defined Familial Hypercholesterolemia in Iceland". Arterioscler Thromb Vasc Biol 2021; 42:e44-e45. [PMID: 34936472 DOI: 10.1161/atvbaha.121.317188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tycho R Tromp
- Department of Vascular Medicine, Amsterdam UMC, location AMC, the Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam UMC, location AMC, the Netherlands
| | - Laurens F Reeskamp
- Department of Vascular Medicine, Amsterdam UMC, location AMC, the Netherlands
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20
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Chua YA, Razman AZ, Ramli AS, Mohd Kasim NA, Nawawi H. Familial Hypercholesterolaemia in the Malaysian Community: Prevalence, Under-Detection and Under-Treatment. J Atheroscler Thromb 2021; 28:1095-1107. [PMID: 33455995 PMCID: PMC8560842 DOI: 10.5551/jat.57026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 10/29/2020] [Indexed: 11/15/2022] Open
Abstract
AIM Familial hypercholesterolaemia (FH) is the most common autosomal dominant lipid disorder, leading to severe hypercholesterolaemia. Early detection and treatment with lipid-lowering medications may reduce the risk of premature coronary artery disease in FH patients. However, there is scarcity of data on FH prevalence, detection rate, treatment and control with lipid-lowering therapy in the Malaysian community. METHODS Community participants (n=5130) were recruited from all states in Malaysia. Blood samples were collected for lipid profiles and glucose analyses. Personal and family medical histories were collected by means of assisted questionnaire. Physical examination for tendon xanthomata and premature corneal arcus were conducted on-site. FH were clinically screened using Dutch Lipid Clinic Network Criteria. RESULTS Out of 5130 recruited community participants, 55 patients were clinically categorised as potential (Definite and Probable) FH, making the prevalence FH among the community as 1:100. Based on current total population of Malaysia (32 million), the estimated number of FH patients in Malaysia is 320,000, while the detection rates are estimated as 0.5%. Lipid-lowering medications were prescribed to 54.5% and 30.5% of potential and possible FH patients, respectively, but none of them achieved the therapeutic LDL-c target. CONCLUSION Clinically diagnosed FH prevalence in Malaysian population is much higher than most of the populations in the world. At community level, FH patients are clinically under-detected, with majority of them not achieving target LDL-c level for high-risk patients. Therefore, public health measures are warranted for early detection and treatment, to enhance opportunities for premature CAD prevention.
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Affiliation(s)
- Yung-An Chua
- Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Aimi Zafira Razman
- Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Anis Safura Ramli
- Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
- Departments of Primary Care Medicine, Universiti Teknologi MARA, Selayang, Selangor, Malaysia
| | - Noor Alicezah Mohd Kasim
- Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
- Pathology, Faculty of Medicine, Universiti Teknologi MARA, Selayang, Selangor, Malaysia
| | - Hapizah Nawawi
- Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
- Pathology, Faculty of Medicine, Universiti Teknologi MARA, Selayang, Selangor, Malaysia
- Specialist Lipid and Coronary Risk Prevention Clinics, Clinical Training Centre, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
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21
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Successful Genetic Screening and Creating Awareness of Familial Hypercholesterolemia and Other Heritable Dyslipidemias in the Netherlands. Genes (Basel) 2021; 12:genes12081168. [PMID: 34440342 PMCID: PMC8392502 DOI: 10.3390/genes12081168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/17/2022] Open
Abstract
The genetic screening program for familial hypercholesterolemia (FH) in the Netherlands, which was embraced by the Dutch Ministry of Health from 1994 to 2014, has led to twenty years of identification of at least 1500 FH cases per year. Although funding by the government was terminated in 2014, the approach had proven its effectiveness and had built the foundation for the development of more sophisticated diagnostic tools, clinical collaborations, and new molecular-based treatments for FH patients. As such, the community was driven to continue the program, insurance companies were convinced to collaborate, and multiple approaches were launched to find new index cases with FH. Additionally, the screening was extended, now also including other heritable dyslipidemias. For this purpose, a diagnostic next-generation sequencing (NGS) panel was developed, which not only comprised the culprit LDLR, APOB, and PCSK9 genes, but also 24 other genes that are causally associated with genetic dyslipidemias. Moreover, the NGS technique enabled further optimization by including pharmacogenomic genes in the panel. Using such a panel, more patients that are prone to cardiovascular diseases are being identified nowadays and receive more personalized treatment. Moreover, the NGS output teaches us more and more about the dyslipidemic landscape that is less straightforward than we originally thought. Still, continuous progress is being made that underlines the strength of genetics in dyslipidemia, such as discovery of alternative genomic pathogenic mechanisms of disease development and polygenic contribution.
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22
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Ibrahim S, Defesche JC, Kastelein JJP. Beyond the Usual Suspects: Expanding on Mutations and Detection for Familial Hypercholesterolemia. Expert Rev Mol Diagn 2021; 21:887-895. [PMID: 34263698 DOI: 10.1080/14737159.2021.1953985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Familial hypercholesterolemia (FH) is a highly prevalent condition, predisposing individuals to premature cardiovascular disease and with a genetic basis more complex than initially thought. Advances in molecular technologies have provided novel insights into the role of next-generation-sequencing, the assessment and classification of newly found variants, the complex genotype-phenotype correlation, and the position of FH in the context of other dyslipidaemias.Areas covered: Understanding the scope of genetic determinants of FH has expanded substantially. This article reviews the current literature on the complexity that comes with this incremental knowledge and highlights the added value of genetic testing as an addition to phenotypic diagnosis of FH. Moreover, we discuss the broad genetic basis of FH, with a focus on the three main FH genes, but we also pay attention to polygenic hypercholesterolemia as well as minor and modulator genes involved in FH.Expert opinion: Both the availability and the need for genetic analysis of FH are on the rise as costs of sequencing continue to drop and new therapies require a genetic diagnosis for reimbursement. However, greater use of genetic testing requires more education of healthcare professionals, since molecular technologies will allow for rapid and accurate evaluation of large numbers of detected variants.
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Affiliation(s)
- Shirin Ibrahim
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joep C Defesche
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - John J P Kastelein
- Department of Vascular Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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23
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Meshkov AN, Ershova AI, Kiseleva AV, Shalnova SA, Drapkina OM, Boytsov SA. The Prevalence of Heterozygous Familial Hypercholesterolemia in Selected Regions of the Russian Federation: The FH-ESSE-RF Study. J Pers Med 2021; 11:464. [PMID: 34074024 PMCID: PMC8225162 DOI: 10.3390/jpm11060464] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/13/2021] [Accepted: 05/20/2021] [Indexed: 11/16/2022] Open
Abstract
Heterozygous familial hypercholesterolemia (HeFH) is one of the most common genetic conditions but remains substantially underdiagnosed. The aim of our study was to investigate the prevalence of HeFH in the population of 11 different regions of Russia. Individuals were selected from the Epidemiology of Cardiovascular Risk Factors and Diseases in Regions of the Russian Federation Study. All participants who had low-density lipoprotein cholesterol (LDL-C) higher than 4.9 mmol/L, or LDL-C lower than 4.9 mmol/L, but had statin therapy, were additionally examined by FH experts. FH was diagnosed using the Dutch Lipid Clinic Network criteria, incorporating genetic testing. HeFH prevalence was assessed for 18,142 participants. The prevalence of patients with definite or probable HeFH combined was 0.58% (1 in 173). A total of 16.1% of patients with definite or probable HeFH had tendon xanthomas; 36.2% had mutations in one of the three genes; 45.6% of FH patients had coronary artery disease; 63% of HeFH patients received statins; one patient received an additional PCSK9 inhibitor; no patients received ezetimibe. Only 3% of patients reached the LDL-C goal based on 2019 ESC/EAS guidelines. Underdiagnosis and undertreatment of FH in Russia underline the need for the intensification of FH detection with early and aggressive cholesterol-lowering treatment.
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Affiliation(s)
- Alexey N. Meshkov
- Federal State Institution, National Medical Research Center for Therapy and Preventive Medicine, Min-istry of Healthcare of the Russian Federation, Petroverigsky per., 10, bld. 3, 101000 Moscow, Russia; (A.I.E.); (A.V.K.); (S.A.S.); (O.M.D.)
| | - Alexandra I. Ershova
- Federal State Institution, National Medical Research Center for Therapy and Preventive Medicine, Min-istry of Healthcare of the Russian Federation, Petroverigsky per., 10, bld. 3, 101000 Moscow, Russia; (A.I.E.); (A.V.K.); (S.A.S.); (O.M.D.)
| | - Anna V. Kiseleva
- Federal State Institution, National Medical Research Center for Therapy and Preventive Medicine, Min-istry of Healthcare of the Russian Federation, Petroverigsky per., 10, bld. 3, 101000 Moscow, Russia; (A.I.E.); (A.V.K.); (S.A.S.); (O.M.D.)
| | - Svetlana A. Shalnova
- Federal State Institution, National Medical Research Center for Therapy and Preventive Medicine, Min-istry of Healthcare of the Russian Federation, Petroverigsky per., 10, bld. 3, 101000 Moscow, Russia; (A.I.E.); (A.V.K.); (S.A.S.); (O.M.D.)
| | - Oxana M. Drapkina
- Federal State Institution, National Medical Research Center for Therapy and Preventive Medicine, Min-istry of Healthcare of the Russian Federation, Petroverigsky per., 10, bld. 3, 101000 Moscow, Russia; (A.I.E.); (A.V.K.); (S.A.S.); (O.M.D.)
| | - Sergey A. Boytsov
- National Medical Research Center for Cardiology, 3-ya Cherepkovskaya Street, 15A, 121552 Moscow, Russia;
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Yeang C, Willeit P, Tsimikas S. The interconnection between lipoprotein(a), lipoprotein(a) cholesterol and true LDL-cholesterol in the diagnosis of familial hypercholesterolemia. Curr Opin Lipidol 2020; 31:305-312. [PMID: 33027223 DOI: 10.1097/mol.0000000000000713] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Elevated levels of lipoprotein(a) [Lp(a)] are present in 30-50% of patients with familial hypercholesterolemia. The contribution of Lp(a) towards risk stratification of patients with familial hypercholesterolemia has been recently recognized, with studies showing a significantly worse prognosis if Lp(a) is elevated. However, the role of elevated Lp(a) in diagnosis of familial hypercholesterolemia is less well defined or accepted. RECENT FINDINGS An important confounder in the diagnosis of familial hypercholesterolemia is the significant contribution of the cholesterol content on Lp(a) (Lp(a)-C) in individuals with elevated Lp(a). Because Lp(a)-C is incorporated into all clinical LDL-C measurements, it can contribute significantly to the cholesterol threshold diagnostic criteria for familial hypercholesterolemia used in most clinical algorithms. SUMMARY In this review, we discuss the interrelationship of Lp(a), Lp(a)-C and correct LDL-C in the diagnosis and prognosis of familial hypercholesterolemia. Future studies of accurately measuring correct LDL-C or in using apoB-100 and Lp(a) criteria may overcome the limitations of using estimated LDL-C in the diagnosis of familial hypercholesterolemia in individuals with concomitant elevation of Lp(a).
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Affiliation(s)
- Calvin Yeang
- Vascular Medicine Program, Sulpizio Cardiovascular Center, Division of Cardiology, University of California San Diego, La Jolla, California, USA
| | - Peter Willeit
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sotirios Tsimikas
- Vascular Medicine Program, Sulpizio Cardiovascular Center, Division of Cardiology, University of California San Diego, La Jolla, California, USA
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Ibrahim S, Reeskamp LF, Stroes ESG, Watts GF. Advances, gaps and opportunities in the detection of familial hypercholesterolemia: overview of current and future screening and detection methods. Curr Opin Lipidol 2020; 31:347-355. [PMID: 33027222 DOI: 10.1097/mol.0000000000000714] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Studies reaffirm that familial hypercholesterolemia is more prevalent than initially considered, with a population frequency of approximately one in 300. The majority of patients remains unidentified. This warrants critical evaluation of existing screening methods and exploration of novel methods of detection. RECENT FINDINGS New public policy recommendations on the detection of familial hypercholesterolemia have been made by a global community of experts and advocates. Phenotypic tools for diagnosing index cases remain inaccurate. Genetic testing is the gold standard for familial hypercholesterolemia and a new international position statement has been published. Correction of LDL cholesterol (LDL-C) for the cholesterol content of lipoprotein(a) [Lp(a)] may increase the precision of the phenotypic diagnosis of familial hypercholesterolemia. Cascade cotesting for familial hypercholesterolemia and elevated Lp(a) levels provides a new opportunity to stratify risk in families. Digital technology and machine learning methods, coupled with clinical alert and decision support systems, lead the way in more efficient approaches for detecting and managing index cases. Universal screening of children, combined with child-parent cascade testing, appears to be the most effective method for underpinning a population strategy for maximizing the detection of familial hypercholesterolemia. SUMMARY Detection of familial hypercholesterolemia can be enhanced by optimizing current diagnostic algorithms, probing electronic health records with novel information technologies and integrating universal screening of children with cascade testing of parents and other relatives.
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Affiliation(s)
- Shirin Ibrahim
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Laurens F Reeskamp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gerald F Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Crawley
- Lipid Disorders Clinic, Cardiometabolic Service, Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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26
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Hamasaki M, Kotani K. Lipoprotein(a) and Familial Hypercholesterolemia: A Short Review Including the Laboratory Viewpoint. Cardiol Res 2020; 11:356-359. [PMID: 33224379 PMCID: PMC7666595 DOI: 10.14740/cr1145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/18/2020] [Indexed: 12/11/2022] Open
Abstract
Lipoprotein(a) (Lp(a)) and low-density lipoprotein cholesterol (LDL-C) are risk factors for cardiovascular disease (CVD). Individuals with familial hypercholesterolemia (FH) have a risk for CVD due to a high LDL-C value. Lp(a) also increases the CVD risk in FH individuals; thus, the Lp(a) value should be carefully managed. The LDL-C value may partly include Lp(a)-cholesterol (Lp(a)-C) in the measurement. Based on the LDL-C value, some individuals are likely misclassified as having FH and/or the status of treatment of FH can be monitored. The present review describes about Lp(a) in FH individuals in terms of the measurement issue of Lp(a) and the related management of FH.
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Affiliation(s)
- Masato Hamasaki
- Division of Community and Family Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-City, Tochigi 329-0498, Japan
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-City, Tochigi 329-0498, Japan
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27
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Fatica EM, Meeusen JW, Vasile VC, Jaffe AS, Donato LJ. Measuring the contribution of Lp(a) cholesterol towards LDL-C interpretation. Clin Biochem 2020; 86:45-51. [PMID: 32997972 DOI: 10.1016/j.clinbiochem.2020.09.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Lipoprotein(a) [Lp(a)] is a pro-atherogenic and pro-thrombotic LDL-like particle recognized as an independent risk factor for cardiovascular disease (CVD). The cholesterol within Lp(a) (Lp(a)-C) contributes to the reported LDL-cholesterol (LDL-C) concentration by nearly all available methods. Accurate LDL-C measurements are critical for identification of genetic dyslipidemias such as familial hypercholesterolemia (FH). FH diagnostic criteria, such as the Dutch Lipid Clinic Network (DLCN) criteria, utilize LDL-C concentration cut-offs to assess the likelihood of FH. Therefore, failure to adjust for Lp(a)-C can impact accurate FH diagnosis and classification, appropriate follow-up testing and treatments, and interpretation of cholesterol-lowering treatment efficacy. OBJECTIVE In this study, we use direct Lp(a)-C measurements to assess the potential misclassification of FH from contributions of Lp(a)-C to reported LDL-C in patient samples submitted for advanced lipoprotein profiling. METHODS A total of 31,215 samples submitted for lipoprotein profiling were included. LDL-C was measured by beta quantification or calculated by one of three equations. Lp(a)-C was measured by quantitative lipoprotein electrophoresis. DLCN LDL-C cut-offs were applied to LDL-C results before and after accounting for Lp(a)-C contribution. RESULTS Lp(a)-C was detected in 8665 (28%) samples. A total of 940 subjects were reclassified to a lower DLCN LDL-C categories; this represents 3% of the total patient series or 11% of subjects with measurable Lp(a)-C. CONCLUSION Lp(a)-C is present in a significant portion of samples submitted for advanced lipid testing and could cause patient misclassification when using FH diagnostic criteria. These misclassifications could trigger inappropriate follow-up, treatment, and cascade testing for suspected FH.
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Affiliation(s)
- Erica M Fatica
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Jeffrey W Meeusen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Vlad C Vasile
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Allan S Jaffe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Leslie J Donato
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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Pang J, Sullivan DR, Hare DL, Colquhoun DM, Bates TR, Ryan JDM, Bishop W, Burnett JR, Bell DA, Simons LA, Mirzaee S, Kostner KM, Nestel PJ, Wilson AM, O'Brien RC, Janus ED, Clifton PM, Ardill JJ, Chan DC, van Bockxmeer F, Watts GF. Gaps in the Care of Familial Hypercholesterolaemia in Australia: First Report From the National Registry. Heart Lung Circ 2020; 30:372-379. [PMID: 32873489 DOI: 10.1016/j.hlc.2020.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/26/2020] [Accepted: 07/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Familial hypercholesterolaemia (FH) is under-diagnosed and under-treated worldwide, including Australia. National registries play a key role in identifying patients with FH, understanding gaps in care and advancing the science of FH to improve care for these patients. METHODS The FH Australasia Network has established a national web-based registry to raise awareness of the condition, facilitate service planning and inform best practice and care services in Australia. We conducted a cross-sectional analysis of 1,528 FH adults enrolled in the registry from 28 lipid clinics. RESULTS The mean age at enrolment was 53.4±15.1 years, 50.5% were male and 54.3% had undergone FH genetic testing, of which 61.8% had a pathogenic FH-causing gene variant. Only 14.0% of the cohort were family members identified through cascade testing. Coronary artery disease (CAD) was reported in 28.0% of patients (age of onset 49.0±10.5 years) and 64.9% had at least one modifiable cardiovascular risk factor. The mean untreated LDL-cholesterol was 7.4±2.5 mmol/L. 80.8% of patients were on lipid-lowering therapy with a mean treated LDL-cholesterol of 3.3±1.7 mmol/L. Among patients receiving lipid-lowering therapies, 25.6% achieved an LDL-cholesterol target of <2.5 mmol/L without CAD or <1.8 mmol/L with CAD. CONCLUSION Patients in the national FH registry are detected later in life, have a high burden of CAD and risk factors, and do not achieve guideline-recommended LDL-cholesterol targets. Genetic and cascade testing are under-utilised. These deficiencies in care need to be addressed as a public health priority.
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Affiliation(s)
- Jing Pang
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | - David R Sullivan
- Department of Chemical Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - David L Hare
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia; Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - David M Colquhoun
- School of Medicine, University of Queensland, Brisbane, Qld, Australia; Wesley Medical Centre, Wesley Hospital and Greenslopes Private Hospital, Brisbane, Qld, Australia
| | - Timothy R Bates
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia; Department of Medicine, St John of God Hospital Midland, Perth, WA, Australia; Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | | | - Warrick Bishop
- Department of Cardiology, Calvary Cardiac Centre, Calvary Health Care, Hobart, Tas, Australia
| | - John R Burnett
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia; Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, WA, Australia
| | - Damon A Bell
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia; Lipid Disorders Clinic, Cardiometabolic Services, Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, WA, Australia
| | - Leon A Simons
- University of New South Wales and St Vincent's Hospital, Sydney, NSW, Australia
| | - Sam Mirzaee
- Monash Cardiovascular Research Centre, MonashHeart, Melbourne, Vic, Australia
| | - Karam M Kostner
- Department of Cardiology, Mater Hospital, University of Queensland, Brisbane, Qld, Australia
| | - Paul J Nestel
- Baker Heart & Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Andrew M Wilson
- Department of Cardiology, St. Vincent's Hospital, Melbourne, Vic, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia
| | - Richard C O'Brien
- Austin Clinical School, University of Melbourne, Melbourne, Vic, Australia; Department of Endocrinology, Austin Health, Melbourne, Vic, Australia
| | - Edward D Janus
- Western Health Chronic Disease Alliance, Western Health, Melbourne, Vic, Australia; Department of Medicine, Western Health Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia
| | - Peter M Clifton
- Department of Endocrinology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Dick C Chan
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | - Frank van Bockxmeer
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia; Department of Cardiology, Calvary Cardiac Centre, Calvary Health Care, Hobart, Tas, Australia.
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Reeskamp LF, Tromp TR, Defesche JC, Grefhorst A, Stroes ESG, Hovingh GK, Zuurbier L. Next-generation sequencing to confirm clinical familial hypercholesterolemia. Eur J Prev Cardiol 2020; 28:875-883. [PMID: 34298557 DOI: 10.1093/eurjpc/zwaa451] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Familial hypercholesterolemia is characterised by high low-density lipoprotein-cholesterol levels and is caused by a pathogenic variant in LDLR, APOB or PCSK9. We investigated which proportion of suspected familial hypercholesterolemia patients was genetically confirmed, and whether this has changed over the past 20 years in The Netherlands. METHODS Targeted next-generation sequencing of 27 genes involved in lipid metabolism was performed in patients with low-density lipoprotein-cholesterol levels greater than 5 mmol/L who were referred to our centre between May 2016 and July 2018. The proportion of patients carrying likely pathogenic or pathogenic variants in LDLR, APOB or PCSK9, or the minor familial hypercholesterolemia genes LDLRAP1, ABCG5, ABCG8, LIPA and APOE were investigated. This was compared with the yield of Sanger sequencing between 1999 and 2016. RESULTS A total of 227 out of the 1528 referred patients (14.9%) were heterozygous carriers of a pathogenic variant in LDLR (80.2%), APOB (14.5%) or PCSK9 (5.3%). More than 50% of patients with a Dutch Lipid Clinic Network score of 'probable' or 'definite' familial hypercholesterolemia were familial hypercholesterolemia mutation-positive; 4.8% of the familial hypercholesterolemia mutation-negative patients carried a variant in one of the minor familial hypercholesterolemia genes. The mutation detection rate has decreased over the past two decades, especially in younger patients in which it dropped from 45% in 1999 to 30% in 2018. CONCLUSIONS A rare pathogenic variant in LDLR, APOB or PCSK9 was identified in 14.9% of suspected familial hypercholesterolemia patients and this rate has decreased in the past two decades. Stringent use of clinical criteria algorithms is warranted to increase this yield. Variants in the minor familial hypercholesterolemia genes provide a possible explanation for the familial hypercholesterolemia phenotype in a minority of patients.
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Affiliation(s)
- Laurens F Reeskamp
- Department of Vascular Medicine, University of Amsterdam, The Netherlands
| | - Tycho R Tromp
- Department of Vascular Medicine, University of Amsterdam, The Netherlands
| | - Joep C Defesche
- Department of Clinical Genetics, University of Amsterdam, The Netherlands
| | - Aldo Grefhorst
- Department of Experimental Vascular Medicine, University of Amsterdam, The Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, University of Amsterdam, The Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, University of Amsterdam, The Netherlands
| | - Linda Zuurbier
- Department of Clinical Genetics, University of Amsterdam, The Netherlands
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Reeskamp LF, Tromp TR, Defesche JC, Grefhorst A, Stroes ES, Hovingh GK, Zuurbier L. Next-generation sequencing to confirm clinical familial hypercholesterolemia. Eur J Prev Cardiol 2020:2047487320942996. [PMID: 32718233 DOI: 10.1177/2047487320942996] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Familial hypercholesterolemia is characterised by high low-density lipoprotein-cholesterol levels and is caused by a pathogenic variant in LDLR, APOB or PCSK9. We investigated which proportion of suspected familial hypercholesterolemia patients was genetically confirmed, and whether this has changed over the past 20 years in The Netherlands. METHODS Targeted next-generation sequencing of 27 genes involved in lipid metabolism was performed in patients with low-density lipoprotein-cholesterol levels greater than 5 mmol/L who were referred to our centre between May 2016 and July 2018. The proportion of patients carrying likely pathogenic or pathogenic variants in LDLR, APOB or PCSK9, or the minor familial hypercholesterolemia genes LDLRAP1, ABCG5, ABCG8, LIPA and APOE were investigated. This was compared with the yield of Sanger sequencing between 1999 and 2016. RESULTS A total of 227 out of the 1528 referred patients (14.9%) were heterozygous carriers of a pathogenic variant in LDLR (80.2%), APOB (14.5%) or PCSK9 (5.3%). More than 50% of patients with a Dutch Lipid Clinic Network score of 'probable' or 'definite' familial hypercholesterolemia were familial hypercholesterolemia mutation-positive; 4.8% of the familial hypercholesterolemia mutation-negative patients carried a variant in one of the minor familial hypercholesterolemia genes. The mutation detection rate has decreased over the past two decades, especially in younger patients in which it dropped from 45% in 1999 to 30% in 2018. CONCLUSIONS A rare pathogenic variant in LDLR, APOB or PCSK9 was identified in 14.9% of suspected familial hypercholesterolemia patients and this rate has decreased in the past two decades. Stringent use of clinical criteria algorithms is warranted to increase this yield. Variants in the minor familial hypercholesterolemia genes provide a possible explanation for the familial hypercholesterolemia phenotype in a minority of patients.
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Affiliation(s)
- Laurens F Reeskamp
- Department of Vascular Medicine, University of Amsterdam, The Netherlands
| | - Tycho R Tromp
- Department of Vascular Medicine, University of Amsterdam, The Netherlands
| | - Joep C Defesche
- Department of Clinical Genetics, University of Amsterdam, The Netherlands
| | - Aldo Grefhorst
- Department of Experimental Vascular Medicine, University of Amsterdam, The Netherlands
| | - Erik Sg Stroes
- Department of Vascular Medicine, University of Amsterdam, The Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, University of Amsterdam, The Netherlands
| | - Linda Zuurbier
- Department of Clinical Genetics, University of Amsterdam, The Netherlands
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Greco MF, Sirtori CR, Corsini A, Ezhov M, Sampietro T, Ruscica M. Lipoprotein(a) Lowering-From Lipoprotein Apheresis to Antisense Oligonucleotide Approach. J Clin Med 2020; 9:jcm9072103. [PMID: 32635396 PMCID: PMC7408876 DOI: 10.3390/jcm9072103] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/24/2020] [Accepted: 07/01/2020] [Indexed: 12/11/2022] Open
Abstract
It is well-known that elevated lipoprotein(a)—Lp(a)—levels are associated with a higher risk of cardiovascular (CV) mortality and all-cause mortality, although a standard pharmacotherapeutic approach is still undefined for patients with high CV risk dependent on hyperlipoproteinemia(a). Combined with high Lp(a) levels, familial hypercholesterolemia (FH) leads to a greater CVD risk. In suspected FH patients, the proportion of cases explained by a rise of Lp(a) levels ranges between 5% and 20%. In the absence of a specific pharmacological approach able to lower Lp(a) to the extent required to achieve CV benefits, the most effective strategy today is lipoprotein apheresis (LA). Although limited, a clear effect on Lp(a) is exerted by PCSK9 antagonists, with apparently different mechanisms when given with statins (raised catabolism) or as monotherapy (reduced production). In the era of RNA-based therapies, a new dawn is represented by the use of antisense oligonucleotides APO(a)Lrx, able to reduce Lp(a) from 35% to over 80%, with generally modest injection site reactions. The improved knowledge of Lp(a) atherogenicity and possible prevention will be of benefit for patients with residual CV risk remaining after the most effective available lipid-lowering agents.
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Affiliation(s)
- Maria Francesca Greco
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
| | - Cesare R. Sirtori
- Dyslipidemia Center, A.S.S.T. Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Alberto Corsini
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
- IRCCS Multimedica, 20099 Milan, Italy
| | - Marat Ezhov
- National Medical Research Center of Cardiology of the Ministry of Health, Moscow, Russia;
| | - Tiziana Sampietro
- U.O. Lipoapheresis and Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, 56126 Pisa, Italy;
| | - Massimiliano Ruscica
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
- Correspondence: ; Tel.: +39-0250318220
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Lipoprotein(a) and Atherosclerotic Cardiovascular Disease: Current Understanding and Future Perspectives. Cardiovasc Drugs Ther 2020; 33:739-748. [PMID: 31655942 DOI: 10.1007/s10557-019-06906-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To review current knowledge of elevated lipoprotein(a) [Lp(a)] levels in relation to atherosclerotic cardiovascular disease (ASCVD) and discuss their potential use as biomarkers and therapeutic approaches in clinical practice. METHODS We summarized the current understanding and recent advances in the structure, metabolism, atherogenic mechanisms, standardized laboratory measurement, recommended screening populations, and prognostic value of Lp(a), with a special focus on the current potential treatment approaches for hyperlipoprotein(a)emia in patients with ASCVD. RESULTS Lp(a) is composed of LDL-like particle and characteristic apolipoprotein(a) [apo(a)] connected by a disulfide bond. Substantial evidence shows that elevated plasma Lp(a) level is a heritable, independent, and possibly causal risk factor for ASCVD through its proatherogenic, proinflammatory, and potentially prothrombotic properties. Current guidelines recommend Lp(a) measurement for patients with an intermediate-high risk of ASCVD, familial hypercholesterolemia, a family history of early ASCVD or elevated Lp(a), and progressive ASCVD despite receiving optimal therapy. Traditional Lp(a)-lowering approaches such as niacin, PCSK9 inhibitors, mipomersen, lomitapide, and lipoprotein apheresis were associated with a non-specific and limited reduction of Lp(a), intolerable side effects, invasive procedure, and high expense. The phase 2 randomized controlled trial of antisense oligonucleotide against the apo(a) encoding gene LPA mRNA showed that IONIS-APO(a)-LRX could specifically reduce the level of Lp(a) by 90% with good tolerance, which may become a promising candidate for the prevention and treatment of ASCVD in the future. CONCLUSIONS It is reasonable to measure Lp(a) levels to reclassify ASCVD risk and manage individuals with elevated Lp(a) to further reduce the residual risk of ASCVD, especially with IONIS-APO(a)-LRX.
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Pang J, Abraham A, Vargas-García C, Bates TR, Chan DC, Hooper AJ, Bell DA, Burnett JR, Schultz CJ, Watts GF. An age-matched computed tomography angiographic study of coronary atherosclerotic plaques in patients with familial hypercholesterolaemia. Atherosclerosis 2020; 298:52-57. [PMID: 32171980 DOI: 10.1016/j.atherosclerosis.2020.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/28/2020] [Accepted: 03/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolaemia (FH) is characterised by a high, but variable risk of premature coronary artery disease (CAD). Cardiac computed tomography angiography (CCTA) can be employed to assess subclinical coronary atherosclerosis. We investigated the features and distribution of coronary artery plaques in asymptomatic patients with and without genetically confirmed heterozygous FH. METHODS We undertook an aged-matched case-control study of asymptomatic phenotypic FH patients with (cases, M+) and without (controls, M-) an FH-causing mutation. Coronary atherosclerosis was assessed by CCTA and calcium scoring. Coronary segments were evaluated for global and vessel-level coronary plaques and degree of stenosis. RESULTS We studied 104 cases and 104 controls (mean age 49.9 ± 10.4 years), who had a similar spectrum of non-cardiovascular risk factors. Pre-treatment plasma LDL-cholesterol was higher in the M+ than M- group (7.8 ± 2.1 vs 6.2 ± 1.2 mmol/L, p<0.001). There was a greater proportion of patients with mixed and calcified plaque, as well as a higher coronary artery calcium score and segment stenosis score (all p<0.05), in the M+ compared with the M- group. M+ patients also had a significantly higher frequency of coronary artery calcium in the left main and anterior descending and right coronary arteries (all p<0.05), but not in the left circumflex. CONCLUSIONS Among patients with phenotypic FH, those with a genetically confirmed diagnosis had a higher frequency and severity of coronary atherosclerotic plaques, and specifically more advanced calcified plaques.
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Affiliation(s)
- Jing Pang
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Arun Abraham
- Department of Diagnostic Imaging, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Cristian Vargas-García
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Timothy R Bates
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia; St John of God Midland Public and Private Hospitals, Midland, Western Australia, Australia; Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Dick C Chan
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Amanda J Hooper
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia
| | - Damon A Bell
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - John R Burnett
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Carl J Schultz
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia.
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Familial hypercholesterolaemia: evolving knowledge for designing adaptive models of care. Nat Rev Cardiol 2020; 17:360-377. [DOI: 10.1038/s41569-019-0325-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2019] [Indexed: 01/05/2023]
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Page MM, Bell DA, Watts GF. Widening the spectrum of genetic testing in familial hypercholesterolaemia: Will it translate into better patient and population outcomes? Clin Genet 2019; 97:543-555. [PMID: 31833051 DOI: 10.1111/cge.13685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/25/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022]
Abstract
Familial hypercholesterolaemia (FH) is caused by pathogenic variants in LDLR, APOB or PCSK9. Impaired low-density lipoprotein (LDL) receptor function leads to decreased LDL catabolism and premature atherosclerotic cardiovascular disease (ASCVD). Thousands of LDLR variants are known, but assignation of pathogenicity requires accurate phenotyping, family studies and assessment of LDL receptor function. Precise, genetic diagnosis of FH using targeted next generation sequencing allows for optimal treatment, distinguishing FH from pathogenically distinct disorders requiring different treatment. Polygenic hypercholesterolaemia resulting from an accumulation of LDL cholesterol-raising single nucleotide polymorphisms (SNPs) could also be suspected by this approach. Similarly, ASCVD risk could be estimated by broader sequencing of cholesterol and non-cholesterol-related genes. Both of these areas require further research. The clinical management of FH, focusing on the primary or secondary prevention of ASCVD, has been boosted by PCSK9 inhibitor therapy. The efficacy of PCSK9 inhibitors in homozygous FH may be partly predicted by the LDLR variants. While expanded genetic testing in FH is clinically useful in providing an accurate diagnosis and enabling cost-effective testing of relatives, further research is needed to establish its value in improving clinical outcomes.
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Affiliation(s)
- Michael M Page
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Department of Clinical Biochemistry, Western Diagnostic Pathology, Perth, Australia
| | - Damon A Bell
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital and Royal Perth Hospital, Perth, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia.,Department of Clinical Biochemistry, Clinipath Pathology, Perth, Australia
| | - Gerald F Watts
- School of Medicine, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Australia.,Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, Australia
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Familial Hypercholesterolaemia in 2020: A Leading Tier 1 Genomic Application. Heart Lung Circ 2019; 29:619-633. [PMID: 31974028 DOI: 10.1016/j.hlc.2019.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 11/26/2019] [Accepted: 12/03/2019] [Indexed: 12/15/2022]
Abstract
Familial hypercholesterolaemia (FH) is caused by a major genetic defect in the low-density lipoprotein (LDL) clearance pathway. Characterised by LDL-cholesterol elevation from birth, FH confers a significant risk for premature coronary artery disease (CAD) if overlooked and untreated. With risk exposure beginning at birth, early detection and intervention is crucial for the prevention of CAD. Lowering LDL-cholesterol with lifestyle and statin therapy can reduce the risk of CAD. However, most individuals with FH will not reach guideline recommended LDL-cholesterol targets. FH has an estimated prevalence of approximately 1:250 in the community. Multiple strategies are required for screening, diagnosing and treating FH. Recent publications on FH provide new data for developing models of care, including new therapies. This review provides an overview of FH and outlines some recent advances in the care of FH for the prevention of CAD in affected families. The future care of FH in Australia should be developed within the context of the National Health Genomics Policy Framework.
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Langsted A, Nordestgaard BG. Lipoprotein(a) Should Be Measured in All Individuals Suspected of Having Familial Hypercholesterolemia. Clin Chem 2019; 65:1190-1192. [DOI: 10.1373/clinchem.2019.308650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Anne Langsted
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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